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Facts about the on-site survey process

September 12, 2014

The Joint Commission survey process is data-driven, patient-centered and focused on evaluating actual care processes. The objectives of the survey are not only to evaluate the organization, but to provide education and “good practice” guidance that will help staff continually improve the organization’s performance. Joint Commission on-site surveys are designed to be organization-specific, consistent and to support the organization’s efforts to improve performance. Survey length is determined by information supplied on the application.

Unannounced surveysAn organization can have an unannounced survey between 18 and 36 months after its previous full survey (24 months for laboratories, which have their survey prior to when their accreditation expires). Most organizations receive no notice of the survey date prior to the start of the survey, unless it would not be logical or feasible to conduct an unannounced survey, such as with Department of Defense and Bureau of Prisons facilities. In addition, some organizations receive a seven-day notice because of size, caseload or surveyors needing advance security clearance. For details, see the Facts about the unannounced survey process.

The on-site visit The on-site survey focuses on continuous operational improvement in support of safe, high quality care, treatment and services. The survey agenda includes activities such as:

Survey planning session

Opening conference and orientation to the organization

Leadership session

Tracer methodology. The cornerstone of The Joint Commission survey, the tracer methodology uses actual patients, residents or individuals served as the framework for assessing standards compliance.

Individual tracers follow the experience of care for individuals through the entire health care process.

System tracers evaluate the integration of related processes and the coordination and communication among disciplines and departments in those processes. The system tracers are specific time slots devoted to in-depth discussion and education regarding the use of data in performance improvement (as in core measure performance and the analysis of staffing), medication management, infection control, and other current topics of interest to the organization.

Competence assessment process

Medical Staff Credentialing and Privileging (Hospitals only)

Environment of care session, which includes a building tour

Exit conference. The survey team presents a written summary of the survey findings.

After the surveyShortly after the survey, an organization’s report of survey findings is posted on the organization’s secure Joint Commission Connect® extranet. If an organization does not receive any requirements for improvement (RFIs), the accreditation decision becomes official at the same time that the organization’s summary report is available, and is effective the day after the completion of the survey. If an organization receives RFIs, then the organization’s accreditation decision is made after the submission of an acceptable evidence of standards compliance (ESC) report.

Quality Check®When an organization’s accreditation decision becomes official, it is publicly disclosed. The decision will be posted to Quality Check® within one business day of being posted to the extranet. Quality Check is the online guide to Joint Commission accredited and certified health care organizations in the United States.